For physicians, consulting in their surgeries, "interaction" is a constituent part of their work. Studying the interactional organization of a consultation, and especially studying the ways in which a doctor 'formats' the consultation, is studying a doctor-at-work.
As Erving Goffman (1961) has suggested, physicians' dealings with patients are complicated by the fact that the position a patient has in medical encounters is an ambiguous one. On the one hand, a patient is an object-to-be-repaired, trusted in the hands of one or several professional 'tinkerers'. But on the other, he or she is, at the same time, a subject and owner of this object, which cannot be separated form him or her. Goffman focusses his discussion on the case of psychiatry, where a problematic subject is the object of discussion and treatment. But even when physical ailments are concerned, the moral situation can be quite complicated. The owner-subject is not only held accountable for monitoring the functioning of the object, but also may be seen as responsible for any malfunctionings that might be caused by neglect or harmful treatment. In the case of psychiatry, a person in the position of next-of-relation to the patient is often put in the position of deputy or guardian, as a substitute owner of the defective object (Goffman, 1961). In non-psychiatric medical situations, a similar pattern exits when the patient is seen as more or less incompetent to take care of himself or herself, as with children (cf. Strong, 1979), and more ambiguously, elderly or physically handicapped persons.
The medical situation, then, basically involves three positions or identities: first, the professional repair worker, such as a physician; second, the to-be-repaired object, the patient's body or personality; and, third, the owner or deputy-owner, responsible for the object in one or another way. The first and last identities have a moral character, involving persons who can think, act, speak and take responsibility. They figure in what Erving Goffman (1974: 22) has called a social framework, while position two involves a non-moral object in a natural one.
The present paper presents a case study of one particular GP consultation which seems to be slightly more problematic than the basic structure of medical encounters suggests. A first, but quite common, complication is that the doctor has to deal with two interlocutors at one, a mother and her daughter. A second, rather covert, complication is that the mother seems to have quite firm beliefs regarding the diagnosis and treatment of her daughter's ailment, which she, however, only voices after the physician has had his say. What I will discuss, then, is how this particular GP manages a consultation with these particular 'complications' and how this relates to the moral identities involved.
Many studies of doctor-patient interaction (cf. Fisher & Todd, 1983; Frankel, 1984, 1990; West, 1984) have focussed on the observation that consultations are interactionally dominated by the physicians. Some of my own work (Ten Have, 1991 b, 1993, 1995a), tends to take a polemical position vis à vis such analyses. In contrast to broadly formulated 'critical' observations, I have focussed on subtle forms of negotiation, with patients arranging their presentations, informations and reactions in such a way, that the doctor provides the service they seem to want, without explicitly asking for it. In other words, without denying that the physician carries the major responsibility for managing their meeting, I have stressed the fact that patients have and often take the opportunity to influence the proceedings in subtle but substantial ways.
One could say that consultations can be analyzed in two ways. On the one hand, they can be considered as structured events, as I suggested above. But on the other hand, they can also be seen as 'interactional streams', that is as locally negotiated sequences of interrelated actions, such as questions and answers, stories and appreciations, informings and acknowledgements. I don't think a choice has to be made between these two 'models'. On the contrary, I think that an adequate analysis requires a combination of these perspectives. In fact, I am convinced that participants themselves use both of these perspectives together, to understand and construct consultations as they go along. The 'structural' view suggests an established progression of 'slots' to be filled by the participants. Seeing consultations as 'interactional streams', implies that such slot-filling activities are negotiated among the participants. The slots themselves are interactionally constituted. This is what I call 'formatting the consultation'.
A related perspective has been formulated by Anssi Peräkylä and David Silverman (1991), in a discussion of Communication Formats in AIDS counseling. They have found that two "simple sets of locally managed conversational roles", the Interview Format and the Information Delivery Format, "cover most of the talking done: the counsellor and the patient are respectively aligned either as the Questioner and the Answerer, or as the Speaker and the Recipient" (629)(2). As they show, these forms are mostly initiated by the Counsellors, but collaboratively maintained.
The two stable formats have at least two features in common regarding the local identities they allocate to the participants. First, in both of them the C is in an initiatory role and the P in a responsive one (cf. Greatbatch 1988). The Cs initiate the actions which project the adequate next action by the Ps. This also entails control of the topical focussing and the opening and closing of the consultation. Second, in both stable formats, the C is allocated a knowledgeable identity. In information delivery, this is realized in the production of specialist knowledge; and in interview, it means a warrant to ask questions and sometimes to evaluate the answers.
Now I take a sustained look at one consultation as an example, to see how 'formatting' is done. The reader is invited to first read the entire transcript of this consultation, to get an overview of the interactional context within which the episodes to be considered in detail later have been enacted.
At the start of the consultation, the parties 'arrange' their meeting, including in this case the appropriateness of the patient party entering the consulting room at this moment, and the presence of an observer (lines 01-09). Then there is a pause (line 09, 2.4. sec.), during which the mother (M) apparently comes to the conclusion that the doctor is ready for her to start. As Christian Heath (1986) has demonstrated, such conclusions tend to be based on a subtle negotiation of visual displays. Whether something similar take place here can not be decided, since my analysis is only based on an audio recording.
The mother provides the reason for the consultation in an accumulation of prudently formulated claims, descriptions and further explanations concerning her daughter, while the doctor abstains from verbal intervention (lines 10-26). It is only towards the end (line 27) that the physician produces an acknowledgement, which seems to 'announce' his upcoming resumption of a more active role (cf. Jefferson, 1984). Then there is another pause (line 28, 2.2 sec.), which can be seen as a product of both parties waiting for the other, to either continue the complaint presentation, or to take over speakership. It finally is the physician who does take over (lines 29-39), addressing the child in a way that is, for him, as for many other doctors, a typical way to address children, with a strong assessment (29) and 'jolly' instructions for a physical examination (33) (cf. Ten Have, 1991 b).
When one part of the examination is completed, the mother volunteers additional descriptions (lines 40-49), supported by the doctor by abstaining from intervention, a 'formulation' (45, cf. Heritage & Watson, 1979, 1980) and an acknowledgement (48). Then, the physician returns for a moment to a questioning of the child, in a kind of summing-up fashion (50-53). In line 54, the physician starts an announcement of a further examination (55) and presents his provisional diagnosis (56), followed by some further remarks (lines 57-63). The mother, however, adds her own comments to the effect that she was expecting just this, because her child has been suffering from the same ailment earlier (64-69). The physician limits his engagement with this to an acknowledgment (69) and, after a pause (1.6; line 70), stresses the provisional status of his diagnosis and re-announces the examination (72).
In the following episode (lines 74-140) the GP seems to write in the patient's record (inferable at 74; hearably at 109-13), while he engages the child in some social talk (81-84), mixed with some further consideration of her condition (88-97). His efforts to engage the child in talk are not very successful, however. The mother, again, volunteers more descriptions (98-108; 134-140), to which the doctor gives no verbal attention whatsoever (cf. Ten Have, 1991 a).
After this, the physician announces an examination, the taking of a blood sample, which is done in another room (141-152). He uses the same 'jolly' tone we saw earlier, as he does when they return (lines 147-151). The result of the bloodtest is announced as positive (153) and discussed with the mother, who participates very actively in this (168-171), where she again, as she did earlier in lines 58 and 64-68, let it be known that she has been expecting this diagnosis all along. The GP, however, again restricts his engagement with this to minimal acknowledgements (170, 172).
The mother succeeds, however, to provoke him into an extensive discussion (173-249) of the logic of the proposed therapy, i.e. iron tablets, by mentioning the possibility, which she apparently has been considering of initiating this therapy herself (173), to which she adds a suggestion of the necessity of long duration (174). The physician takes this up in two parts. First, he mentions that there is a disagreement on the therapy itself, to which he adds his own 'practical' considerations (176-206). Then, he takes up the issue of duration (207-247), calling her earlier statement in 174 a 'question' (208), explaining the necessity of building an emergency supply. The mother actively collaborates in these explanations, with informations (184-5), numerous minimal responses and formulations (240, 248-9). Toward the end of this phase, the GP is evidently writing the prescription (244).
In lines 250-259 the doctor, in collaboration with the mother, prepares for the closing by adding an 'escape clause' to the earlier promise of success. Then, in 261-265, the actual closing takes place.
The second CF (29-53) roughly corresponds with the Interview Format with the physician as interviewer, and the child as interviewee, with the mother adding ad lib responses. As is often the case in medical setting, instructions for physical cooperation in the examination are mixed with the questioning as such. This CF establishes the doctor (interviewer and examiner) as the inquiring subject and the patient as object. The mother, here, takes up an ambiguous position as a reporter on the object.
The third CF (54-72) takes off as an Information Delivery Format, but the comments by the mother, first her soft spoken confession that she has been thinking along the same lines (58), and then her report on an earlier instance of the same ailment, involving a different doctor (64-68), 'threatens' this format and might have lead to a transformation into another one, a kind of Discussion Format which would place the participants on a more equal footing, as a kind of colleagues (cf. Strong, 1979). One could suggest, then, that although the mother has postponed this positioning of herself as a co-discussant until the physician has had 'the first word' on the case, this re-footing is silently refused by the doctor. He just acknowledges the factual part of her contribution in a minimal fashion, stresses the preliminary status of the just given diagnosis, and re-announces the blood test.
The fourth CF (74-140) returns the consultation to the Interview Format, with the additions discussed earlier, i.e. recapitulations, suggestive descriptions and some 'social talk' by the doctor, and volunteered reports by the mother. The child proves to be, like many children, a rather reluctant interviewee, especially in the second part, which probably induces the adults to produce their extensive contributions. I would suggest that the rather abrupt shift from the third to the fourth CF, by re-establishing the conventional distribution of identities, served to strengthen the doctor's 'refusal' to follow the mother in her 'proposed' transformation of the IDF into a collegiate Discussion Format.
The fifth CF, the actual blood test (143-7), even further strengthens the identities of the doctor as professional producer of knowledge and the child as object thereof. One might say that is such a situation, the Interview Format, is transformed in such a way that 'the body' is made to 'speak' for the Interviewer, who is 'objectified' through the use of medical technology. The mother, as spokesperson, is also 'put aside', as the doctor takes the child to another room.
When the doctor returns with the child (147), however, the mother is immediately put in the position of a receiver of information, first jokingly as the one whose child has been mistreated, then seriously regarding the test result. In short, the sixth CF, one of Information Delivery is started, and takes us to the closing which is prepared from line 250, and enacted in 261-265.
In this long episode, we see another instance of the mother 'proposing' to turn the IDF into a collegiate Discussion Format, by positioning herself as a 'thinker' (168) who already expected the information just delivered (169), although she is unsure about the details of the practical implications (174). She is more successful this time, in the sense that the doctor systematically takes up the issues she raises, although in an authoritative fashion, even when he presents professional opinion as 'divided'. She is now fully recognized as a subject, but kept in her place as a to be informed lay person. She does collaborate in this re-positioning, by actively displaying her reception of the information given.
In most GP consultations, especially with 'new' complaints, the patient is expected to start of as a Speaker in an IDF, to account for the initiative to consult and present a (set of) complaint(s). This relates to the fact that most GP-consultations are patient initiated and take off from patient provided information. Return visits (cf. Heath, 1981) and visits arranged for the delivery of test results are often organized in a different manner, although patients may be invited to provide a kind of information update(4).
In medical consultations generally, the IF can be transformed into, or mixed with, an alternative form of information production, the physical examination or test format (PEF). Rather than being a reporting subject, the patient is then constituted as a to be examined object, a living body 'owned' by the patient-as-subject. As we saw, there is a range of 'mixtures' of IF and PEF, with different subject/object combinations(5).
As I suggested from the start, in medical consultations involving child patients or other kinds of less competent persons, the interactional givens of the consultation are complicated in various ways. Firstly, the IF is complicated by the fact that the parent often acts as a reporter on the child, based on his or her own observations and/or the child's own reports in the home environment. The physician may address either the child or the parent or both, while parents often volunteer information while the doctor questions the child. And secondly, the IDF is mostly formatted to address the parent, unless the child's collaboration is expressly sought(6). As the person responsible for the child's well-being, the parent has an ambiguous and ambivalent position regarding a child's health problems. The basic subject/object ambiguity of patients is in this case separated into a patient/object and a parent/deputy-owner.
In the case examined, we find a number of these 'complications'. The two major CF's, the IF and the IDF, are used, but mostly more or less transformed. This is for IF related to the fact that there are two possible 'interviewees'. Independent of who is addressed by the doctor, the other party in this case only the mother - can also provide answers or not expressly invited information as an elaboration attached to the just given answer (cf. Mazeland, 1992, on the extendibility of question/answer sequences). Furthermore, and to a lesser extent, we see the PEF transforming the IF.
As usual in GP-consultations, the IDF is used in two ways: first for the patient's complaint presentation - in this case done by the mother, and second for various instances of the delivery of professional information, concerning diagnosis and treatment. I argued that the mother displayed a partly covert tendency to transform the IDF into a more egalitarian, 'collegial' Discussion Format, which seemed to be countered by the physician in various ways. In the first instance, the 'challenge' is ignored, while it the second it is taken up, but in a fashion that returns the interaction to a collaboratively asymmetrical IDF.
The identities, implied in the various formats, can be seen to be re-negotiated time and again. The child sticks to her 'object'-status most of the time. She keeps very quiet during the times her case is discussed among the adults, while she only reluctantly lets herself be engaged as a 'subject', when she is directly addressed. The physician at times makes quite an effort to do so, however, only after she has been the 'object' of an IDF, i.e. the complaint presentation.
The mother has a subject-status throughout, although the physician tends to put her 'on hold' as he engages the child. Her status as a subject is ambivalent, however, as regards the amount of initiative she is allowed to take successfully. After her first IDF, the complaint, her volunteered contributions tend to be ignored or just acknowledged, until the physician addresses her as a recipient of diagnostic and treatment information in his long, final IDF. When she challenges the asymmetry of this format as he uses it, by reporting on her own thoughts and experiences, he seems rather reluctant to grant her such a status, at least not before he is finished, and then only as a to-be-informed lay person.
The physician's subject-status involves a much more secure active participation throughout. The only time he is clearly passive is during the complaint presentation. For the rest of the time, he tends to either give or request information, or listen and receive information he has requested. The mother's eagerness to give additional information during the questioning of her daughter and to share her own ideas challenge the secure-active position of the doctor. As we saw, the physician ignores or just minimally acknowledges the unsolicited informations and the first effort to share thoughts, while the second effort to share is turned into a request for information and explanation.
In short, the child is very passive indeed; the mother's more or less covert initiatives are not really taken up, i.e. ignored, just acknowledged or transformed; the physician himself is the one who initiates all of the consultation's structural progressions (31, 54, 72, 143, 153). At two different moments, the conversation seems to slow down a bit, the first is just after the mother has mentioned her own thoughts (i.e. 64-68). During this period (74-133), he is doing some 'social' talk, some questioning and formulating for the child, as well as record keeping. The second 'slow down' follows the mother's second effort to share thoughts (i.e. 168-175), when the physician gives quite elaborate explanations regarding blood shortage and the duration of iron therapy (176-256). One might suggest that when the physician is engaged in such 're-positioning work' in response to these half-covered challenges, the progress of the consultation slows down.
Michael Lynch has consistently criticized CA's efforts to analyze professional activities, such as the work of doctors(8). In general terms, his criticism is that CA-based analyses of such work necessarily focus on general aspects of such work, such as sequential structures, and ignore those aspects that make the work into essentially medical work. In order to study those aspects, the analyst would have to be 'medically competent', to satisfy a minimal level of what Garfinkel has termed the 'unique adequacy requirement'. To my mind, such a criticism is essentially correct if one's goal is to built a basic analysis of the essential properties of such work. It is absolutely evident that physicians' work involves more than 'doing interaction', or 'formatting the consultation'. Ideally, one should acquire a quite extensive medical competence before analyzing medical work. For many, including myself, this is not a realistic option. Rather than turning to the study of practices that involve only generally available competencies or abilities that I happen to be knowledgeable about, I have chosen to take the medical work of organizing interaction seriously in its own terms, not as the essence of medical work, but as an important part of it, at least in General Practice.
2. Peräkylä & Silverman refer to Erving Goffman's concept of 'footing' (Goffman, 1981), and one might as well think of the related concept of 'participation status' (Goffman, 1974).
3. This summary statement does not, of course, do full justice to the complexities of AIDS counseling as a genre on its own; cf. Peräkylä, 1995, and Silverman, 1996.
4. Maynard (1989, 1991, 1992) has analyzed such 'perspective display' invitations as a professional strategy to prepare of the delivery of diagnostic news.
5. As Christian Heath (1986, 1988, 1989) has shown, patients often collaborate in their 'objectivation' by dis-attending the examined body parts and the physician's examining actions.
6. In one consultation I analyzed, a child is brought to the GP by his mother for problems of bed-wetting; in this case the doctor strategically addressed the child himself and even arranged for the next consultation to be with the child alone, evidently in order to constitute him as the one responsible for the problem, and able to solve it on his own as well.
7. On the idea that CA is a data-driven approach to interaction, see the introduction to Atkinson & Heritage (1984). On Goffman's method, in itself and in contrast to CA, see Drew & Wootton (1988).
8. C.f. Bjelic & Lynch, 1992, and more generally, Lynch, 1985, 1993; I have summarized and commented on this critique in Ten Have, 1990, 1995b).
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